P - 39801Building
Inspections
763-572-3604
763-502-4977 FAX
DATE � " � / `
SITE ADDRESS _�
THIS APPLICANT IS:
PROPERTY
OWNER/
TER'ANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE, BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE I-I-201 I
YOUR E-MAIL ADDRESS
! r.� �+ a. .
❑ OWNER \�YJCONTRACTOR
NAME: ILQl�12CC� IL@Q/l @�✓l
ADDRESS:_O�l3� L�S+c1.? ,�j r'iCt,vc* CITY
PHONE: TE7.3 - �Iy J -9 �5.3
NAME: c7 a
�.
��
Permit No.:
�- -. : r
-�a
�.�,- ,- � , •,;� 1
ATE�YIP 3�i'%3L,
STATE LICENSE # �S`i' c3S 3 r EXP DATE /3 -3l - i I
3TATE BON !O� F-` �� EXP DATE
ADDRESS: �� �.,�j6 (r l a� CITY c.�(�.,�t... STATEj��ZIP S__��__t �
PHONE %lS3• �CI�/- �%�-`�oZ. FAX �J63' S�Iy �S� %�
�Sj diG�rLE FAMILY
❑ NEW
t] TWO FAMILY ❑ TOWNHOUSE
�EPLACEMENT
DETAI D DES PTION OF WORK �f�C.� iL►`'��I..,t�•. S i i•K� }�,^�,�GQ�}.� � �,s.pd•,� �
� 17is�Wces4 � °
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTUKES: (3NDICATE TOTAL NUMBER OF EACN BELOW). MINIMUM FEE
$35.50.
BATH SINKlLAV FLOOR DRAINS SHOWER WATER PIPING
SATHTI3B GAS PIPING (NEED CITY LIC) SWIMMING POOL ` WATER 50FTNER ($35)
CLOTHES WASHER � KITCHEN SINK WATER CLOSET BACKFLOW PREV. ($15)
+DISHWASHER _ LAUNDRY TRAY WATER HEATER ($35) � FOR IRRIGATION
^ WATER METER OTHER
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a plumbing permit and I acknowledge that the information above is complete and accurate; that the work wiil be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the c e of I wo k which requires review and approv 1 of pla s.
SIGNATURE QF APPLICANT �„�_-�� PRINT NAME ��Gys�e�.r—+ DATE �' (�7-- � j
APPROVALINSPECTOR3SIGNAT DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977